1. ___Mr. ___Mrs._________________/____________________/___________________
                                    Family Name                   First Name                  Middle Initial

2. Student's Mailing Address: _________________________________________________
                                             Street Address or P.O. Box
                                             _________________________________________________
                                             City                       Postal Code                         Country

3. Date of Birth: _____/_____/_____

4. Nationality: _____________________    Native Language: ________________________

5. Beginning Session Date: _____/_____/_____

6. Beginning Date With Homestay Program: _____/_____/_____

7. Please rank your English conversational ability: (Circle One)  LOW   MEDIUM   HIGH

8. Level of Education completed: (e.g. Secondary, College/University) ___________________

9. What is your current or future occupation? ______________________________________

10.What are your hobbies or special interests? _____________________________________

11.What are favorite sporting activities? __________________________________________

12.Please circle one to answer these questions.(Y=Yes, NR=No preference N=No)
Would you prefer a family with small children?     Y   NR   N
Would you be comfortable with a family which has household pets?    Y   NR   N
Do you drink alcohol beverages? Y   NR   N
Would you be comfortable with a family which drinks alcoholic beverages?  Y   NR   N
Do you smoke?    Y   NR   N
Would you be comfortable with a family which has members that smoke?  Y   NR   N
Are there any foods that you cannot eat?   Y   NR   N

** Please list any food you cannot eat, allergies, or health problems: ____________________
_______________________________________________________________________

13. In case of emergency, please contact:
Name: ______________________         Phone:    _____________________
Address: ________________________________________________________________

_________________________________             _____/_____/_____
Signature of Applicant                                              Date: